Prolonged sitting is a silent killer according to new report in the Annals of Internal Medicine (Jan 2015).

According to a new study published in the Annals of Internal Medicine (Jan 2015) if you are sitting for greater than eight hours per day you can expect to die sooner than your peers. Even for those who exercise regularly, prolonged sitting is associated with increased incidences of heart attacks, diabetes and cancer. For those who don't exercise regularly we see even higher rates of disease and mortality.

Here are some tips that will help you get out of your chair at work and at home.

  • Schedule a short break each hour to stand up to get a drink of water. While you are up you can do some stretches.
  • If you frequently find yourself in the zone while working on a project and the hours start to slip by then here's one for you. Take a kitchen timer and put it on the other side of the office where you can't reach it or roll to it. Set the timer for 30-45 minutes and when the alarm sounds you will be forced to leave your desk to switch it off.
  • Get an adjustable standing desk. This will help you to alternate between seated and standing positions while you work. If you missed a few days of work last year due to neck or back pain then this is a great investment.
  • Take the stairs instead of the elevator and park at the back of the lot.
  • Drink more water and your bladder will get you out from behind your desk on a regular basis.
  • Schedule walking meetings. For small meetings that only include two or three people see if you can get your co-workers to go for a walk while you discuss the agenda items.
  • Move a treadmill or stationary bike into the family room. Now, when you watch television you can get your heart moving.

I hope these tips are helpful to everyone out there that rides a desk and punches computer keys all day. You may find that your neck or back is giving you problems due to all that sitting. If that is the case then come on down and see what we can do to help with that.


FDA issues stronger warning for non aspirin NSAID's in regards to increased risk of heart attack and/or stroke.

Looking for an alternative to NSAID's for back pain? Try Chiropractic care.

Looking for an alternative to NSAID's for back pain? Try Chiropractic care.

As of July 2015 the FDA has issued a stronger warning in regards to the risk for heart attack or stroke from non-aspirin medications known as non steroidal anti inflammatory drugs (NSAID's). This includes popular over the counter medications such as Ibuprofen, Aleve, Motrin and Advil. The common perception among many Americans is that these drugs do not have any adverse side effects. This information should help individuals and families make informed choices in regards to wise consumption of pain medications. The "drug facts" labels will be updated to include the following information. 

  • The risk of heart attack or stroke can occur as early as the first weeks of using an NSAID. The risk may increase with longer use of the NSAID.
  • The risk appears greater at higher doses.
  • It was previously thought that all NSAIDs may have a similar risk. Newer information makes it less clear that the risk for heart attack or stroke is similar for all NSAIDs; however, this newer information is not sufficient for us to determine that the risk of any particular NSAID is definitely higher or lower than that of any other particular NSAID.
  • NSAIDs can increase the risk of heart attack or stroke in patients with or without heart disease or risk factors for heart disease. A large number of studies support this finding, with varying estimates of how much the risk is increased, depending on the drugs and the doses studied.
  • In general, patients with heart disease or risk factors for it have a greater likelihood of heart attack or stroke following NSAID use than patients without these risk factors because they have a higher risk at baseline.
  • Patients treated with NSAIDs following a first heart attack were more likely to die in the first year after the heart attack compared to patients who were not treated with NSAIDs after their first heart attack.
  • There is an increased risk of heart failure with NSAID use.

If you find yourself taking these medications for prolonged periods or in higher than recommended doses to treat chronic or acute muscle and joint pain then you might want to reconsider your treatment methods. This is a great opportunity for you to take a different approach in managing your pain. I would love to be able to sit down with you and review the treatment options available in my office. 


How to avoid being rear ended

These simple steps can help you reduce the likelihood that you will be hit from behind.

These simple steps can help you reduce the likelihood that you will be hit from behind.

1. Equipment Check

  • Check your brakes, tire tread depth, suspension and most importantly your brake lights to make sure they are in proper working order.

2. Mirrors

  • Adjust your mirrors prior to driving to make sure you can clearly see behind you and that your blind spots are covered. For information on how to properly adjust your mirrors click here. Hint, you're probably doing it wrong.

3. Following Distance

  • You should always maintain an appropriate following distance of two full seconds under ideal driving conditions.
  • Increase following distance up to four seconds in adverse weather, at high speeds, at night, behind motorcycles, when driving a larger than normal vehicle or when towing a trailer.
  • To check your following distance pick a fixed object on the side of the road like a sign post and then count the time between when the vehicle in front of you passes that object and when you pass that object. Count it nice and slow, one thousand and thousand and two, then adjust your distance accordingly.
  • If the driver behind you is following at an unsafe distance or is obviously distracted while driving then safely change lanes or find an opportunity to pull over and let them pass.
  • When you stop during traffic you should be able to see the rear tires of the vehicle in front of you. In stop and go traffic on a freeway this is especially important as vehicles behind you may be approaching at a high rate of speed. This extra gap will leave you with an escape option to the shoulder of the road if necessary.

4. Plan Ahead  

  • Don't just look at the car right in front of you, pay attention to the road well ahead of you so that you can anticipate traffic lights, lane closures, road debris, stopped vehicles or accidents coming up. If the vehicle two cars in front of you is applying the brakes then you should probably take your foot off the gas and prepare to stop as well.
  • Give the drivers behind you plenty of time to react to any stops or turns that you are about to make. If you are approaching a red light and you know that you will have to stop, take your foot off the gas early and apply gentle pressure to the brakes. This will force the vehicle behind you to slow gradually as well. If you wait until the last second to brake aggressively then if the driver behind you is not paying attention they may not be able to stop in time. This will help prolong the life of your brake pads and your wallet will thank you.
  • Use your turn signal well in advance of turning or making lane changes to indicate to other drivers that you will be making a turn.

5. Keep the Pace

  • Avoid driving much slower or faster than the other vehicles around you. This also includes merging into moving traffic. If you are travelling below freeway speeds when you merge into traffic you run the risk of being struck from behind at high speeds which can have fatal consequences. 

6. Pay Attention

  • Avoid multitasking when driving. This includes texting and talking on your phone, screaming at your kids, eating lunch, reading the newspaper and my all time favorite putting on makeup while on the freeway.


I hope that these simple steps can help you avoid the hassle and pain that can follow an auto collision. Despite these precautions some of you will still be involved in a collision through no fault of your own. If you have been hurt in an auto collision then we are here to help you get better and get on with your life.

Eight simple steps to help you prepare for your Las Vegas DOT Physical.

With some simple preparation your next DOT Physical can be a piece of cake.

With some simple preparation your next DOT Physical can be a piece of cake.

Whether you have been driving for decades or are coming in for your very first DOT Physical these 8 simple steps can help you get in, get out and get back on the road.

  1. Prior to scheduling an appointment make sure that the healthcare provider is listed on the National Registry of Certified Medical Examiners. These providers are the only ones authorized to perform DOT Physicals. (You can look me up by searching zip code 89084 or by entering Jacob Fisk in the advanced search box. My NRCME # is 3663109167.) 
  2. Get a good nights sleep prior to your physical and lay off the caffeine as it can artificially increase blood pressure in some people. According to the Mayo Clinic caffeine seems to have a stronger effect on older men and men who are overweight. Nicotine has been shown to cause a short term increase in blood pressure so if you use tobacco products or other forms or nicotine then right before your physical is not the best time for a cigarette.
  3. Bring your last medical certificate with you so that your records are consistent and the examiner has a baseline to start from. Don't forget your driver license as the examiners office will need to verify your identity and use your license number to fill out your certificate.
  4. Your vision will be tested so bring your glasses or contact lenses if you use them to drive. Your hearing will be tested during the exam so if you wear a hearing aid while driving then make sure you are wearing it for the exam.
  5. Drink water prior to your physical as we will need to collect a urine sample. Your urine will be tested to evaluate for blood, protein, specific gravity and glucose. This is not a drug test. Avoid eating a large meal prior to your appointment as it may cause glucose to spill over into the urine of non-diabetic patients. If glucose is detected in your urine the examiner must refer you for further testing to evaluate for diabetes.
  6. If you are currently treating for a health condition such as high blood pressure, diabetes or sleep apnea make sure to bring medical records demonstrating compliance with your treatment plan. 
  7. Bring a list of your prescribed medications as well as the contact information for the doctor who prescribed them. There are times when we must contact the prescribing doctor to determine what condition is being treated by a specific medication. If we don't know who to contact then this can delay getting you back to work.
  8. Make sure you are taking any prescribed medications according to the schedule established by your doctor. The morning of your DOT physical is not a good time to "forget" to take your blood pressure meds.

Thanks for taking the time to read this article and I hope it will help you to prepare for your physical. My wish for each of you is to have a long and successful career as a commercial driver. Having said that, please keep in mind that there are times when a DOT Physical may need to serve as a wake up call regarding your general health. There are instances where I may have to issue a temporary certificate or even disqualify a driver for a period of time due to a variety of health conditions. Some things are easily correctable and can be taken care of quickly such as a new prescription for glasses. Other things are not so simple such as a suspicion of and subsequent diagnosis of diabetes. Some surgeries require significant waiting periods and by law I cannot issue a certificate until that time has passed. I recognize that your livelihood is at stake and I do not make these decisions lightly. My office will do whatever we can to communicate effectively with your treating doctors and get you back to work as soon as regulations allow. We appreciate your trust in coming to our office for your physical and look forward to seeing you soon. 

What to do when you are hurt on the job.

If you are hurt on the job then you need to know what steps to take to get the care you need.

If you are hurt on the job then you need to know what steps to take to get the care you need.

We all know that work injuries happen every day to other people. What happens when you are the one who is hurt on the job? In this post we will cover the six steps you must take to ensure that you get the appropriate medical care you need to help you recover from your injury and how to document permanent impairment if appropriate.

1. Inform your employer

  • Inform your employer of your injury as soon as possible.
  • Fill out the necessary paperwork called a C-1 form or incident report. Be as detailed as possible in describing the mechanism of injury and the body parts involved.
  • Make sure to get statements from anyone who witnessed your injury.

2. Go for an evaluation and get treatment recommendations

  • Do not wait to get evaluation and treatment. It is important that your injuries are assessed promptly so that you can start any necessary treatment. Delays in treatment or gaps in treatment will negatively impact your recovery.
  •  In an emergency situation an ambulance will transport you to the nearest hospital. In non-emergent cases your employer will direct you to their contracted facility for evaluation and treatment recommendations.
  • The first doctor who sees you is required to fill out a form C-4. Again, it is important that you give a concise description of the mechanism of injury and absolutely crucial that you detail each injured body part. I highly recommend that you get a copy of the form C-4 after the doctor finishes and verify that each injured body part is included. This simple step is so important and can save you a lot of time and misery later on. It can be an absolute nightmare to add an injured body part on to a claim once certain deadlines have passed. 
  • Make sure when you see your doctor that each body part is addressed in her/his notes and match them to the included diagnosis list. The records will not be available for immediate review so give them a few days but they are your medical records and you are entitled to review them once they are finished.

4. Consider Legal Representation

  • If you have a significant injury at work then I highly recommend a consultation with an experienced attorney who specializes in workers compensation law. 
  • A qualified legal representative can help you navigate the deadlines and paperwork involved in a work comp case. A missed deadline or exclusion of an injured body part can have significant consequences down the road in terms of treatment, scope of claim and future benefits in the event of permanent impairment.

5. Follow Treatment Recommendations 

  • You actually need to show up for your appointments and then do what your doctor asks you to do so that they can monitor your response to treatment.
  • Don't be scared to ask questions when you see your doctor. If doctors visits make you nervous then come prepared with a short (<5), legible list of questions for your provider.
  • As an impairment rating doctor one of the most frequent complaints I hear from injured workers is that every time they go to their work comp treatment facility they are seen by a different provider. This lack of continuity can cause lots of confusion for the patient and may lead to inconsistent medical records and treatment. Simple statements like, "today I am here for evaluation of x,y and z body parts" can help to mitigate confusion and keep everyone on the same page.
  • Adhere to the work restrictions given to you by your treating doctor. In the event that your symptoms worsen due to following these restrictions or you are physically unable to work within the assigned restrictions then you should return to your provider for further evaluation and recommendations.
  • If you are doing what your providers have asked you to do and for whatever reason you are not improving, worsening under care or are simply not satisfied with the care that you are receiving then you can request that your insurer send you elsewhere.
  • In the event that you request a change of provider it will not happen quickly, if at all. You need to do your best to be compliant with the directions of the previous doctor until a new one is assigned.

6. Claim Closure

  • In a perfect world you will continue with treatment until your symptoms have resolved and you have returned to your pre-injury status. Unfortunately we all know that this is not a perfect world and some people are left with permanent problems following an injury.
  • In the event that you are unable to return to your pre-injury status then the insurer should send you for a permanent and partial disability examination (PPD).
  • As a designated impairment rating doctor for the State of Nevada I am asked to evaluate injured workers as an impartial third party. The purpose of the PPD exam is to determine two important factors. 
  • The first objective is to decide if the injured worker has reached maximum medical improvement (MMI). In plain English this means that you are as good as you are going to get with the treatment available to you at this time. If the examiner decides that you are not at MMI then they should recommend further evaluation by another provider. 
  • The second objective of a PPD exam is to determine if you have sustained any sort of permanent impairment as a result of your work injury. In the event that permanent impairment is detected then an impairment rating is assigned to the injured worker.

I hope that this brief overview of the process for injured workers will help you to navigate the work comp system so you can get the care you need. Of course I would love to see everyone return to their pre-injury status but that is not always the case. In the event that you require a PPD examination then you as the injured worker have the right to request an examining doctor by name and then come to an agreement with the insurer as to who that will be. I strive to be thorough and accurate in my examination and documentation and have worked hard to establish this reputation with insurers, injured workers and plaintiff attorneys. If I can be of assistance to you in any way don't hesitate to contact my office. 

Is a Sleep Apnea diagnosis an inconvenience or a life saver?

Can you remember the last time you woke up feeling refreshed and well rested?

Can you remember the last time you woke up feeling refreshed and well rested?

My father suffered from severe sleep apnea for around twenty years until he was finally diagnosed and treated with a Continuous Positive Airway Pressure or (CPAP) machine. With his permission, I would like to tell you his story. I want you to pay close attention because if this sounds like you or someone you love then the information in this blog post may save your life or the life of someone close to you.

Growing up in our house we knew that if my dad sat down on the couch after dinner instead of going to do something else, within minutes, he would fall asleep and begin snoring very loudly. We are talking chain saws, jet engines and thunder bolts loud. This aural assault would continue for a while and then suddenly it would stop. The whole family would enjoy the peace and quiet for a brief time but if you watched him closely suddenly his whole body would stiffen and he would begin to gasp for air but would not fully wake up. Imagine how you look and feel when you break the surface of the water after a deep dive and your lungs are burning for oxygen. After a few big lungfuls of air he would fall back into a deeper sleep and shortly thereafter the snoring would begin again. This cycle would repeat over and over until we would wake him up and send him to bed or he would go off to work on one of his many projects.

So, if that isn't weird enough for you then check this out. My bedroom was directly above his home office, therefore, I was privy to his bizarre work schedule. Often at two or three in the morning I could hear him doing paperwork in his office or in my later years I would come home in the wee hours to find him puttering around in the garage fixing stuff. This is after he had already worked seeing patients from 8am until 6 or 6:30 at night. I would think to myself, "go to bed already, I can't believe you are still working." Even worse, this crazy old guy would sometimes wake me up in the middle of the night to help him build things in the garage or send me trudging through the snow to work with him in the barn. He would tell me that he couldn't sleep and we might as well get an early start on chores. I would think to myself, "I was sleeping just fine until your crazy carcass woke me up." Over the years we built storage shelves, welded car frames, serviced diesel generators, plowed snow for old ladies and maybe even built a dog house all in the middle of the night. I swear I'm not making this up. The same guy who would fall asleep as soon as he sat down would be up and working in the middle of the night because he couldn't sleep.  

I always chalked up his bizarre sleep schedule to his incredible work ethic. What I didn't know at the time is that he would often wake up at night from a dead sleep gasping for air and then wouldn't be able to fall back to sleep because his heart was racing so fast. So instead of just lying there in bed frustrated with his inability to get any sort of satisfying sleep he would just get dressed and go back to work in the middle of the night. No matter what he did, whether he tried to sleep or just went back to work, my father was always tired. He was even tired in the morning after what he perceived as a full nights sleep. 

I have come to learn that many, but certainly not all of my fathers crazy behaviors can be attributed to a severe case of sleep apnea. Now you are probably thinking that none of this sounds like you. You might snore a little or be a little tired in the morning but it's nothing like the story you just heard. You are probably right because what I have just described is a severe case, but even mild and moderate sleep apnea can have significant health consequences.

Sleep apnea is a common but serious sleep disorder affecting 18 million Americans. This disorder is characterized by pauses in breathing or shallow breaths while sleeping. In severe cases a person may stop breathing hundreds of times per hour. This sleep disorder is not commonly caught on routine physicals and will not show up on any blood test. There are two types of sleep apnea.  

  • Obstructive sleep apnea (OSA) is the most common form and is characterized by a blockage of the airway due to enlarged tonsils or tongue, a short jaw length or when the soft tissue at the back of the throat collapses during sleep.
  • Central sleep apnea (CSA) is the other form and occurs when the brain forgets to tell the appropriate muscles to breathe.
  • Some lucky folks have mixed sleep apnea (MSA) and suffer from characteristics of both types.

Untreated sleep apnea is associated with increased incidence of  the following problems

  • high blood pressure, heart attack, stroke and congestive heart failure
  • daytime fatigue and depression
  • disrupted metabolism, obesity, diabetes and liver problems
  • sleep deprived bed partners (For those who share a bed with someone who has sleep apnea. I want you to know that I feel your pain. I have been on a lot of camping trips with my father and there were times when sleeping out in the rain seemed more appealing than sharing a tent with him.)

Those most at risk for sleep apnea are

  • Males over 40 who are overweight, snore and have a neck circumference greater than 17" (16" for women). As we age the risk for sleep apnea continues to increase particularly in males over 60.
  • Women can also have sleep apnea and it tends to occur with increased weight and is more frequent in post-menopausal women.
  • Evidence suggests that black and latino males may be more susceptible to sleep apnea.
  • Smokers have significantly increased rates of sleep apnea.
  • Children with enlarged tonsils may also suffer from obstructive sleep apnea.

For more information visit the American Sleep Apnea Association or watch this video on the diagnosis and treatment of sleep apnea. Many people report difficulty using a CPAP machine at night because the mask is uncomfortable or becomes dislodged. At the end of the video that I linked to above you will see all the different styles of masks available. I always counsel patients to keep trying different masks until they find the one that works for them.

My father started treating his sleep apnea in my late teenage years. I remember when he told me one time that he had more energy as a 50 year old man than he did when he was 30. Now he takes his CPAP machine with him everywhere. My parents are now retired and living in Africa doing humanitarian work. I am glad to see my father healthy and happy in his later years. When I spoke with him recently he was trying to figure out how to get a special lightweight lithium ion battery over to Malawi so he could take his machine with him on an extended safari camping trip prior to returning to the United States. 

If you or a loved one are experiencing any of the symptoms discussed in this blog post or in the links provided above then I would counsel you to meet with your healthcare providers. They will be able to provide further evaluation and treatment recommendations if appropriate. A diagnosis of sleep apnea followed by appropriate treatment measures may not just be a change for the better it might save your life.






Belly fat: A general predictor of health

For a long and healthy life keep your waist to height ratio at or below 50%

For a long and healthy life keep your waist to height ratio at or below 50%

For many years healthcare providers have used Body Mass Index or BMI to help calculate an optimal weight range for their patients. BMI is calculated by recording a persons weight in kilograms and dividing it by their height in centimeters squared. The body mass index does a good job of describing general fat composition in the body but does a poor job of evaluating where that fat is distributed. The BMI formula will often categorize athletic muscular men as obese when casual observation will tell you that they are clearly not obese. The formula for BMI was calculated for Caucasians and has decreased correlation for other ethnic groups. BMI is also fairly unreliable in growing children.

We now know that people who carry increased fat around the abdomen are at greater risk for cardiovascular disease and diabetes. When we refer to belly fat we are not just addressing the layer of fat between the skin and the abdominal muscles. We also have to take into account what is known as visceral fat. Visceral fat is stored within the abdominal cavity and around our important organs. 

Researchers are now encouraging healthcare providers and patients to use a waist to height ratio when evaluating general health instead of BMI. This formula is an accurate predictor of the amount of belly fat that a person has at a specific point in time. America is an ever expanding nation and using the height to weight ratio can serve as a real wake up call. I would encourage you to take some time today and measure your waist to height ratio. If you have children then tonight is a perfect time to do this activity as a family and then set goals together if change is necessary.

To calculate your waist to height ratio record your waist circumference in inches as measured one inch above the navel/bellybutton and then divide by your height in inches. For instance a person who has a waist circumference of 36 inches and is 5' 6" or 66" tall would have a waist to height ratio of 55%. When you finish with your measurements consult the table below.


  • Ratio less than 42%: underweight
  • Ratio 42% to 48%: healthy weight
  • Ratio 49% to 57%: overweight
  • Ratio over 58%: obese


  • Ratio less than 43%: underweight
  • Ratio 43% to 52%: healthy weight
  • Ratio 53% to 62%: overweight
  • Ratio over 63%: obese

The bottom line and the take home point of this post is you should keep your waist to height ratio at or below 50%. Your body will thank you and so will your loved who are counting on you to be there for many years to come. If you find that you are significantly above or below these values then it is time to talk to your healthcare providers about an immediate strategy to make some changes.